Inpatient Coder

At Houston Methodist, the Inpatient Coder position is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines.

FLSA STATUS

Non-exempt

QUALIFICATIONS

EDUCATION

• Associate’s degree or higher in a CAHIIM accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree

EXPERIENCE

• One year of relevant inpatient coding experience or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program

LICENSES AND CERTIFICATIONS

Required

• Must have one of the following: RHIT - Certified Health Information Technician (AHIMA)
• Must have one of the following: RHIA - Registered Health Information Administrator (AHIMA)
• Must have one of the following: CCS - Certified Coding Specialist (AHIMA)

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance
• Knowledge of an electronic medical record and imaging systems preferred
• Working knowledge of medical terminology, anatomy and physiology
• Proficiency with electronic encoder application preferred
• Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Interacts and communicates effectively with members of the coding team and the appropriate stakeholders.
• Participates and provides good feedback during coding section meetings and coding education inservices as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders.

SERVICE ESSENTIAL FUNCTIONS

• Responds promptly to internal and external customer requests. Responds promptly and appropriately to requests to code or review coded accounts for accuracy.
• Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Maintains and achieves the highest standards of coding quality by assigning accurate/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
• Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.
• Reviews medical record documentation and abstracts data into the encoder and EPIC/Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures. Utilizes all tools/ resources for accuracy.
• Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.

FINANCE ESSENTIAL FUNCTIONS

• Utilizes time effectively. Consistently codes and abstracts at departmental standards of productivity while ensuring accuracy of coding.
• Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts.
• Maintains coding timeframes within established departmental standards by ensuring all work items assigned to the coding queues are processed in a timely manner.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve.
• Displays initiative to improve relative to job function. Contributes ideas to help improve quality of coding data and abstracting data.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*

*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**

**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area Yes